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CUSTOMER MESSAGE TO BNSE MOBILITY
PLEASE ENTER ANY ADDITIONAL INFORMATION ON YOUR MEDICAL EQUIPMENT NEEDS KNOW THE PRIDE PRODUCT AND FEATURES YOU NEED A PRICE ON ENTER HERE
MEDICAL EQUIPMENT VENDOR
MEDICAL EQUIPMENT INTEREST
PLEASE CHECK BELOW
If you know the
Model, Part Number Enter Here:
Manufacture Name
Model Number
Part Number
Check Medical Equipment you need more information about:
Other Medical Equipment
IF WHAT YOU NEED IS NOT SHOWN ABOVE PLEASE ENTER BELOW TELL US THE PRIDE MODEL NAME OF OR TYPE OF EQUIPMENT, AND SPECIAL FEATURES.
Additional information to
meet your individual needs. Tell us your Individual Medical Needs so we can better assist you. Do you qualify for a power wheelchair? Answer these 5 easy questions to find out if you are eligible: 1. Do you have problems throughout the day with your mobility due to your health? Yes No 2. Do you have trouble completing your daily activities due to heart, lung, arthritis, respiratory, stroke, diabetes, or any other health reasons? Yes No 3. If "Yes" to question 2, would a power wheelchair allow you to better complete your daily activities? Yes No 4. Would a power wheelchair give you more independence and freedom of movement? Yes No 5. Can you safely operate a power wheelchair? Yes No If you answered "Yes" to all of the above questions, you may be eligible for insurance coverage for a power wheelchair To Print a Copy of This Information on Your Local Printer Click Print Button Above SUBMIT YOUR REQUEST CLICK SUBMIT Button Above Clear Form and Start Over
Tell us your Individual Medical Needs so we can better assist you.
Do you qualify for a power wheelchair?
Answer these
1. Do you have problems throughout the day with your mobility due to your health?
Yes No
2. Do you have trouble completing your daily activities due to heart, lung, arthritis, respiratory, stroke, diabetes, or any other health reasons?
3. If "Yes" to question 2, would a power wheelchair allow you to better complete your daily activities?
4. Would a power wheelchair give you more independence and freedom of movement?
5. Can you safely operate a power wheelchair?
If you answered "
for insurance coverage for a power wheelchair
To Print a Copy of This Information on Your Local Printer
SUBMIT YOUR REQUEST
CLICK SUBMIT Button Above
Clear Form
Click Reset